FADIC Guide for Travel Medicine and Medication Checklist

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FADIC Guide for Travel Medicine

FADIC Guide for Travel Medicine

Travel medicine is an interdisciplinary speciality devoted to the health of travellers who visit foreign countries.

Travel medicine is concerned explicitly with preventing infectious diseases during travel.

It’s also concerned with ensuring the personal safety of travellers and avoiding environmental risks.

Globalisation facilitates the spread of disease and increases the number of travellers exposed to a different health environment.

The field of travel medicine encompasses a wide variety of disciplines, including

Epidemiology
infectious disease
public health
tropical medicine
high altitude physiology
travel-related obstetrics
psychiatry
occupational medicine
military and migration medicine
environmental health

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Most Common Medications for Travel Diseases

Most standard travel diseases and their treatment:

MALARIA

Malaria is one of the most severe infectious diseases among travellers,

However, almost all travel-related cases are preventable.

The disease is caused by Plasmodium spp., a parasitic protozoan transmitted by female Anopheles mosquitoes.

This mosquito is unique because it is a rural night biter.

Malaria is a tremendous public health problem because more than 40% of the world’s population is at risk.

Malaria is endemic in tropical and subtropical areas of Africa, South America, Asia, and Oceania.

Symptoms:

shaking chills that can range from moderate to severe
high fever
profuse sweating
headache
nausea
vomiting
abdominal pain
diarrhoea
anaemia
muscle pain
convulsions
coma
bloody stools

Prevention:

Travel to malarious areas should be discussed in the pretravel assessment
Bed nets should be used in addition to repellants and

Protective clothing:

Travelers should be adherent to their antimalarial regimen.
Travelers should be encouraged to seek medical attention should fever develop during travel

Chemoprophylaxis for Malaria:

Chloroquine and hydroxyl chloroquine: Start 1–2 wk before travel; continue weekly during and 4 wk after returning

Doxycycline: Start 1–2 days before the trip; continue daily during and 4 wk after returning

Primaquine: Start 1–2 days before the trip; continue daily during and 1 wk after returning

Treatment Options:

Plaquenil:

620 mg base (= 800 mg of salt) PO immediately, followed by 310 mg base (= 400 mg of salt) PO at 6, 24, and 48 hr

Quinine dihydrochloride:

20 mg of salt/kg loading dose infused during 4 hr, followed by maintenance of 10 mg of salt/kg infused over 3–4 hr every 8 hr

Oral therapy can be used to complete a 7-day course (quinine sulfate plus doxycycline

Quinidine gluconate plus doxycycline, tetracycline or clindamycin:

10 mg of salt/kg IV infused over 1–2 hr, followed by a continuous infusion of 0.02 mg of salt/kg/min for at least 24 hr and then until parasitemia < 1%

Doxycycline 100 mg IV/PO twice daily

Tetracycline 250 mg PO four times daily

Clindamycin 20 mg base/kg/day PO divided over three times daily

Clindamycin IV dosing is 10 mg base/kg, followed by 5 mg base/kg three times daily

Traveller’s Diarrhea

TD is the most common illness in individuals travelling from resource-rich to resource-limited regions.

TD is caused by ingesting contaminated food and beverage.

More than 90% will consume unsafe food and drink within days of arriving at their destinations.

Symptoms of TD may resemble or overlap with “food poisoning.”

The aetiology of the disease is determined by geography and can affect the therapy selection.

Of the bacterial causes, enterotoxigenic E. coli is the most common pathogen.

Prevention:

Avoiding foods that travellers cannot boil, cook, or peel themselves
avoidance of the following:
Tap water (including food washed in water)
Unpasteurized milk
Salsas
Raw or undercooked meats
hand washing or use of alcohol-based sanitisers
receipt of vaccines that can prevent food- and waterborne infection. Od from street vendors

Chemoprophylaxis for TD:

1- Bismuth subsalicylate: 2 tablets chewed every 6 hr

2- Ciprofloxacin: 500 mg once or twice daily

Treatment:

1- Bismuth subsalicylate: 2 tablets chewed every 6 hr

2- Loperamide: 4 mg initially; then 2 mg after each unformed stool

3-Short-course antimicrobial therapy (1–3 days) is often effective and decreases the duration of illness to about 1½ days

Ciprofloxacin: 500–750 mg daily for 1–3 days

4- Treatment options for protozoal pathogens include

Tinidazole
Metronidazole
Nitazoxanide

Viral Infections

1- Zika Virus

First mosquito-borne virus with the capacity for sexual transmission.

Flavivirus is closely related to dengue, yellow fever, Japanese encephalitis, and West Nile viruses.

Methods of transmission

Mosquito bite
Blood transfusion
Percutaneous
Sexual contact
Intrauterine
Intrapartum from a viremic mother to newborn

Symptoms:

Rash (maculopapular; often pruritic(
Fever (usually low grade/short term(
Arthritis, myalgias, and arthralgias
Nonpurulent conjunctivitis

Treatment:

Treatment should focus on preventive efforts, including preventing further transmission, employing vector control, and avoiding mosquito bites with repellants.

Currently, no antiviral agent with appreciable activity exists, and supportive care is recommended.

2- Ebola Virus

Belongs to the family Filoviridae, closely related to the Marburg virus.

There are five species of Ebola virus, all of which cause human disease except for R. ebolavirus.

Methods of transmission:

Contact a reservoir host
Person-to-person transmission through blood or body fluids poses the highest risk of transmission.

Symptoms:

Fever (80% of patients)
Severe headache
Fatigue740
Myalgia
Vomiting/diarrhoea
Abdominal pain
Elevated liver function tests
Renal failure
Blood dyscrasias (leukopenia/thrombocytopenia)

Treatment:

There is no known treatment, and care is mainly supportive, including:

Intravenous fluid resuscitation is considered critical in treating patients.
Electrolyte replacement
Empiric antibiotics and/or antimalarials
Respiratory supportive care

3- Dengue

Most common arbovirus infecting humans.

Vectors are A. aegypti and A. albopictus.

Considered endemic in over 100 countries, resulting in an estimated 50 million infections annually.

Increased global travel, urban crowding, and ineffective mosquito control have allowed dengue to become a pandemic.

Transmitted predominantly through mosquitos.

Symptoms:

can be asymptomatic or subclinical.
Often characterised by a febrile state called (breakbone fever)
Typical incubation period is 3–14 days with symptoms following three phases:
Initial febrile phase

Characterized by high temperature with headache, myalgias, vomiting, and joint pain
Resolution is typically 3–7 days later, and most patients recover without further sequelae.

5. Critical phase

typically occurs around the time of defervescence
Clinicians should be aware of this phase because patients can rapidly deteriorate to dengue shock syndrome.
Early signals of possible significant vascular leakage include major skin bleeding, high or increasing hematocrit with a concurrent decrease in platelet counts, lethargy, and restlessness.
Signs and symptoms consistent with disseminated intravascular coagulation can also be present in this phase.

6. Spontaneous recovery/convalescent phase

The vascular leak reverts after 48–72 hours and is associated with improved patient symptoms.
A maculopapular rash may also be present during this phase

Treatment:

Supportive care is the cornerstone of treatment.
Fluid management is imperative.
No antiviral agents with appreciable activity are currently available.
Other therapies that have been investigated include:

Doxycycline
Pentoxifylline
Celgosivir
Ivermectin

4- West Nile Virus

Second-most common flavivirus infection only to dengue.

Methods of transmission:

Transmission is optimal during the summer months.
Warmer temperatures foster infectivity and transmission efficiency.
Transmission occurs almost exclusively by the Culex mosquito

Symptoms:

Headache
Myalgia
Maculopapular or morbilliform nonpruritic rash
Recovery often takes weeks to months.
Up to 50% who develop West Nile neuroinvasive disease have functional and/or cognitive sequelae, particularly with encephalitis.

Treatment:

Preventive strategies, including vector control and use of insect repellants
Management is largely considered supportive

Travel- Borne Rickettsioses

Rickettsioses are obligate intracellular pathogens, with many arthropods serving as competent vectors.

These include lice, fleas, ticks, and mites.

Rickettsioses are divided into three groups:

two diseases in the typhus group
15 diseases in the spotted fever group
one disease in the scrub typhus group

1- Murine Typhus

Also called “endemic typhus” or “flea-borne typhus.”

Rodents and rat fleas serve as the primary vector(s), with endemicity linked to high rat (rodent)

Transmission is closely correlated with fleas versus rodent reservoirs.

Infection often occurs without recognised contact with fleas or associated vectors.

Symptoms:

Nonspecific, with fever and maculopapular rash as the most common features
Incubation period is 7–14 days.749
The rash may be faint or absent in some patients and characteristically spares the palms and soles.
Most disease is benign and self-limited

Treatment:

doxycycline 100 mg twice daily is the treatment of choice in children and non-pregnant females.
Fluoroquinolones and chloramphenicol are alternatives

2- African Tick Bite Fever

Caused by R. africae and found in almost all countries in sub-Saharan Africa and parts of the eastern Caribbean

Closely related to the Mediterranean spotted fever but does not typically cause severe illness.

Considered the most commonly encountered rickettsial infection in travel medicine

Not fully realised in travellers because of the self-limited nature of the disease.

Symptoms:

Headache
neck pain
myalgia
Eschar and localised lymphadenitis

Treatment:

Doxycycline 100 mg twice daily for 5–7 days
Azithromycin and fluoroquinolones are suitable alternatives

3- Mediterranean Spotted Fever

Dog ticks are the principal vectors and reservoirs for the Mediterranean spotted fever and its variants.

Endemic to the “Mediterranean area” of Europe, Africa, and Asia

Transmission is influenced by season (increased transmission in warmer months)

Warmer months increase the tendency of ticks to bite humans

Symptoms:

Incubation period is about six days.
Disease is very similar to African tick bite fever, with fever, maculopapular rash, and black eschar (tache noire) at the site of the tick bite as the most common symptoms.

Treatment:

Doxycycline is the treatment of choice

4- Scrub Typhus

Mite serves as the principal vector and reservoir

Transmitted by the bite of larval trombiculid mites

Associated with travel that includes trekking or camping in rural areas

Scrub typhus is a significant cause of fever in travellers returning from Asia because it is considered predominant.

Symptoms:

Incubation period is typically 7–10 days but may extend to around three weeks.
Lymphohistiocytic vasculitis is pathognomonic for scrub typhus
Can be clinically challenging to differentiate from other diseases

Treatment:

Doxycycline is considered the drug of choice, with azithromycin an alternative.
Treatment should consist of at least three days with doxycycline.
Rifampin as monotherapy is also an alternative regimen.

Immunisation Considerations in Travelers

The CDC and the WHO provides information about vaccines when travelling abroad.

The CDC stratifies vaccines into the following categories:

All travellers
Most travellers
Some travellers

Vaccination Required Before Travelling to Specific Countries

Additional vaccination choice depends on the following:

Region(s) visited within a given country
Planned activities
Duration of stay
Time of the year

Routine Vaccines include:

Influenza
Td (tetanus and diphtheria)
Tdap (tetanus, diphtheria, and pertussis)
HPV (human papillomavirus)
HZV (herpes zoster)
MMR
Hib (Haemophilus influenzae type b)
Pneumococcal
HAV (Havrix, Vaqta, and Twinrix)
Hepatitis B (Engerix-B, Recombivax HB, and Twinrix)
Japanese encephalitis (Ixiaro)
Meningococcal (Menactra and Menomune)
Polio (Ipol)
Rabies (Imovax and RabAvert)
Typhoid (Typhim Vi and Vivotif)
Yellow fever (YF-Vax)

FAQs about travel:

What should you do with your medicines and medical supply if you are flying?

Show your medicines to a security person
Ask for inspection by a person, not an Xray machine
Keep your medication in your carry-on bags so you would have them on the plane

When should I take my medicines if you are changing the time zone?

Talk to your doctor before you travel to work out a travel action plan for you.

How should you reserve your medications if you go to a hot place?

Keep your medicine in a cool, dry place.

Never keep them in the car, bathroom, or in direct sunlight.

How can you avoid blood clots if you often go on long flights?

Walk around every hour during your flight
Bend and straighten your legs every half an hour during your flight
Wear compression stockings
Avoid dehydration by drinking plenty of water
Avoid taking sleeping tablets because they prevent you from walking around

Before you travel:

Find out if you need travel vaccines and ensure your vaccinations are up-to-date.
If malaria is a risk, you may need to start treatment before travelling.
Prepare a kit of travel health essentials, including sunscreen, painkillers and antiseptic.
Keep your medicine in your carry-on bag so you can get to your medicine during your flight
If you have an ongoing health concern, talk to your healthcare provider about your trip.
If you are changing time zone, talk to your doctor to work out a travel action plan for when you should take your medicine
If you are going somewhere with hot and sticky weather, keep your medication in a cool, dry place
Ask your doctor for a letter stating your medical history and prescribed medications.
Carry a medical aid kit with medications and other supplies you need for your trip
To prevent deep venous thrombosis, if you are going to be on a long flight, walk around every hour or so during your flight and try to wear compressing stockings or flight socks.

Travel Medicine Checklist

Summary:

Travel medicine is concerned explicitly with preventing infectious diseases during travel.

Before travelling, ensure you take the vaccination for the destination country.

Avoid any raw, unwashed or non-boiled food.

If you have an ongoing health concern, talk to your healthcare provider about your trip.

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